Why are women's health outcomes in India so poor?

There are several senses in which the health of women and girls can be considered as the basic indicators for the health of a society. Precisely because of gender discrimination, the health conditions of females generally tend to lag behind those of males, and therefore absolute improvement in these conditions is a reasonable indicator that the overall health conditions of that society are also getting better.

In the past two decades, India had the third fastest growing economy in the Asian region (after China and Vietnam) and it is generally perceived, even in a period of continuing global crisis, as an emerging economic powerhouse.

Table 1 presents India's growth performance in the past two decades in relation to three other Asian countries. Vietnam grew slightly faster than India but still has slightly lower per capita income.

Sri Lanka is richer on average but has growth more slowly, while Bangladesh is still clearly a low income country, where per capita income has increased, though more slowly than these other countries.

To what extent was this period of economic expansion in India reflected in better health outcomes for women and girls? To examine this, we consider two crucial health indicators: the female Infant Mortality Rate (IMR or number of deaths per 1,000 children below one year) and the Maternal Mortality Ratio (MMR or number of childbirth-related deaths per 1,00,000 live births).

Poor showing on female IMR

Chart 1 shows that in terms of female infant mortality rates, India is, by far, the worst performer in this group, with the slowest rate of decline.

Even Bangladesh, which is much poorer and has slower national income growth, managed to bring the female IMR down faster. And the Indian rate is more than two-and-a-half times that of Vietnam, which has a lower per capita income.

The evidence on maternal mortality is equally disturbing. India and Bangladesh both have very high rates, many multiples of those in Sri Lanka and Vietnam. But even here, the rate of reduction of this ratio has been marginally faster in Bangladesh.

Of course, India is also very regionally diverse, with some states, such as Kerala, showing excellent health outcomes for women, similar to those in Vietnam. And three states have also shown much improved health indicators in the past two decades: Tamil Nadu, West Bengal and Maharashtra.

But the bulk of the country still shows generally appalling levels of female IMR and MMR. One important reason for high infant and child mortality is under-nutrition, which has actually worsened in recent times, according to indicators such as calorie consumption. Rising prices of food are making this problem worse as women and girls in poor households take the brunt of food scarcity.

Chart 3 shows how closely the rate of child mortality tracks the proportion of underweight children across Indian states.

Public spending, immunisation

Nutrition is important, but it is not the only concern. To deliver better health outcomes, public expenditure on health service delivery is absolutely essential, and this is especially important for women and girl children. Here again, India fares badly.

Public spending on health (Chart 4) is a minuscule amount in relation to GDP, and around two-third of health expenditure is out-of-pocket payment by households. This is indeed an important reason for families falling into poverty or remaining destitute, and gender biases reinforce the relative denial of health to women and girls in such conditions.

Even in absolute per capita terms, public health spending in India is around half that in Vietnam, which is a country with lower per capita income. And it is just above one-third of the level in Sri Lanka. It is true that Bangladesh shows a much lower level, but then Bangladesh also has a much lower per capita income.

So it is no wonder that other indicators of health service delivery also appear quite inadequate with respect to the other countries.

Chart 6 shows that less than half of births are attended by skilled personnel, whereas in Vietnam it is near universal and it is close to that in Sri Lanka. The low proportion here suggests one important reason for the high maternal mortality ratios in India and Bangladesh.

Similarly, immunisation coverage is a necessary element in ensuring child health. Full measles coverage within the first year of life is often taken as a proxy for the extent of immunisation in general, and in this case India fares worst among this set of four countries.

Even Bangladesh has much higher immunisation rates. In some parts of the country, immunisation rates have barely improved. Small wonder, then, that infant mortality rates have come down more slowly in India than in these other countries.

No urgency on sanitation

Another major aspect of ensuring adequate health conditions is the provision of improved sanitation for everyone. This is one of the weakest aspects, along with nutrition: around 70 per cent of the population does not have access to improved toilets.

Remarkably, this does not even appear as a major policy goal for the government, which does not appear to see the urgency in this matter, or the wider health effects, quite apart from the loss of dignity to citizens that comes from forced open defaecation.

All of these factors are crucially determined by government policy. Despite much publicly expressed concern on all these issues, the Government of India has simply not put its money where its mouth is. Public spending as a share of GDP has not increased, and per capita spending on some essential activities such as immunisation and primary health centres has actually gone down.

Instead, the government has sought to provide essential health services on the cheap, using the underpaid labour of local women working for much less than the minimum wage, not properly trained regular public employees with adequate facilities.

positive synergy

The apparently growing divide between economic growth and women's health outcomes in countries such as India is not inevitable: the experience of other Asian countries shows that a more positive synergy can be created, with health spending not just valued for its own sake, but as an essential element in an overall macroeconomic and growth framework oriented to better conditions of human life rather than just GDP expansion.